Adverse Incident Report
Reported by
Name
Position
Phone number
Email Address
Who was involved
Tick all that apply
*
Staff
Patient
Visitor
Complete details for each person involved
Name
Relationship to business
Contact Details
Name
Relationship to business
Contact Details
Name
Relationship to business
Contact Details
Details of Witness
Name
Relationship to business
Contact Details
Name
Relationship to business
Contact Details
If more than 2 people involved, please use comments section at bottom of form.
Location and Time of Incident
Incident Classification
Injury or Adverse Health Event
Exposure to contaminants
Please specify the contaminants
Adverse response to procedure
Topical Creams/Gels
Tape
Manipulation
Treatment
Other - please specify
Sexual Misconduct
Equipment Failure
Further information on Equipment Failure
Act of Aggression
Verbal
Physical
Virtual
Other - please specify
Theft/Missing Property
Breach of Privacy
Computer Breach
Discrimination
Incident Details
Description of Incident
Outline action taken immediately after incident
External Assistance
Police
Fire
Ambulance
Other - please specify
Debriefing
On Site
Referred
For discussion at Directors / Practice Managers Meeting
Yes
No
Report to Physiotherapist Professional Indemnity Insurance Provider
Must be within 24 hours
Incident Review
Name
Position
Contact Details
Remedial Action to be taken
Additional Comments
Signatures
Signature of Reporter
Draw signature
|
Type signature
Clear
Signature of Director
Draw signature
|
Type signature
Clear
Reporter Signature Date
Director Signature Date
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